August’s Lunch&Learn saw Jamie Foster from Hempsons, a leading UK Health & Social Care Law Firm join us for an engaging and well informed discussion on the changing NHS landscape. Hempsons specialise in advising in the healthcare space, working with both start-ups and the NHS.

Jamie’s story began with a case study of Salford City, Manchester to illustrate the changing NHS landscape. Back in 2013 if an elderly resident needed to visit a GP, they would visit one of the 50 or 60 surgeries in the area. If they needed to be referred to hospital Salford Royal, the main hospital in the area had to bid for competitive contracts, the resident might not go there but to another hospital. The complexity continued after they were released. A social worker would turn up at their home and have no idea they’d been to hospital, and a community nurse might turn up having no idea they’d been visited by a social worker. This kind of fragmented care, Jamie explained, was because a quasi-competitive marketplace was in place which meant that services were not integrated.

Contrast this to today. In 2017 Salford is leading the way in healthcare healthtech. Jamie explained this change was due to Salford Royal becoming an organisation with the overall budget and responsibility for health and social care. That same patient's journey very different today.

Instead of 50 or 60 GP practices, the resident might visit one of 4 or 5 GP “super hubs” who co-ordinate and share services. If that resident needed to hospital, they are more likely to go into Salford Royal. On discharge into social care, the resident’s social worker will be briefed on what is happening with this patient and they might even have a care navigator to coordinate their care.

Jamie made the point that the main difference in the NHS landscape today, is that it is now following an accountable care system. But what has brought about this change?

The first factor is Politics. Jamie explained that NHS England’s CEO Simon Stevens is a bit of a thinker and he drove the Five Year Forward View - the policy document that drives change in the NHS today. One of the main goals of the Five Year Forward View was to integrate services rather than have them compete. To deliver this he came up with Sustainability and Transformation Partnerships (STPs). plans are the main way NHS is being driven locally and regionally.

The second driver was Austerity. Because in 2002 Labour raised National Insurance contributions to fund the NHS, the previous system had lots of money in it. But when austerity bit, the system didn’t work.

The third factor is the Americanisation of healthcare in the UK with the introduction of accountable care organisations (ACOs). Jamie referred to this as Americanisation of the NHS as the language of accountable care comes from the United States, where ACOs have taken shape in the wake of Obamacare as an attempt to improve care and reduce growing health care costs. NHS England has recently outlined ambitions for the STPs to evolve into ‘accountable care systems’ (ACSs), and proposed that these ACSs might become ACOs but only after ‘several years’. Eight areas of England have now been identified to lead their development, one being Salford.

Jamie then made the point that health tech start-ups need to understand the structures to understand how the money flows. They need to know who's in control, who has the money for their services and how to navigate through the NHS.

Under the system, there are the Commissioners who are the people who buy the services. These are the Clinical Commissioning Groups, local Councils who are responsible for public health, and NHS England who commission specialist services. Under the Commissioners we have the Providers - GP practices, Provider Trusts eg SLaM and GSTT, and a wealth of other organisations including those from the voluntary and community sector delivering health and social care services. Supply Chain - those selling services into the NHS - which includes start-ups.

With accountable care systems, things look a little different. For example, in Salford Royal they run social care services (with primary care coming on board soon). Instead of a myriad of organisations, there is one organisation running the system. Jamie illustrated this by using the example of care homes. Now that Salford Royal have the contract to run the 400 care homes in the city, it’s easier to discharge someone into better coordinated care.

Next Jamie outlined the role of the Regulators - an important part of the framework that start-ups should understand. NHS Improvement supports Foundation Trusts and NHS Trusts to give patients consistently high quality care. The Care Quality Commission (CQC) is the independent regulator of all health and social care services in England. Healthcare providers such as GPs but also startups need to with the CQC if they are delivering any clinical services. The Medicines and Healthcare products Regulatory Agency (MHRA) is the UK’s regulator of medicines and medical devices and are responsible for ensuring their safety, quality and effectiveness. Last, but not least, the Information Commissioner’s Office (ICO) is an independent authority set up to uphold information rights in the public interest including holding a register of data controllers. They can take action against organisations who are not meeting their information rights obligations. A recent example of this in the digital health space is when it ruled that the Royal Free hospital failed to comply with the Data Protection Act when it handed over personal data of 1.6 million patients to DeepMind. Jamie made the point however that the regulators tend not to give an answer about whether your technology or platform is compliant so his advice was to get a legal opinion on your technology and then proceed.

The next important part of landscape, and often overlooked by start-ups, is the Academic Health Science Networks (AHSNs) and Academic Health Science Centres (AHSCs). The AHSNs are a collaboration between the NHS and academic organisations, local authorities, the third sector and industry. There are 15 AHSNs across England and their role is to identify and spread health innovation at pace and scale. This Innovation Pathway diagram summarises how AHSNs support the entire innovation life cycle of health innovation. Each regional AHSN focuses on different priority areas so it’s worth doing some research about the best one to connect with. Jamie recommended that all start-ups should at least connect with their local AHSN as they are a good way in for startups as they should know what is happening in the local area. The regional AHSN for South London, for example, is the Health Innovation Network (HIN).

The very last piece of the puzzle is knowing the range of programmes and initiatives that are happening in digital health. DigitalHealth.London run an Accelerator for 30 digital health companies each year starting in September. The Digital Catapult have a number of programmes that are relevant to digital health. Sign up to their newsletter to keep up to date. Jamie also recommended keeping an eye on the NHS Test Beds and the Global Digital Exemplars who are NHS care providers delivering exceptional care through the use of world-class digital technology as these Trusts might be more receptive to working with innovators.

Jamie then finished with his top tips for navigating the system:

1. Be aware of the regulatory framework ie know what it is and don’t expect the regulators to help you decide whether you are within the law or not.

2. Understand your data flows and information ie be aware of governance requirements if you are working on anything to do with patient data.

3. Know your customers and build relationships with them and find out who is the payer you need to connect with.

4. Protect your innovation. Owning your IP is crucial and also future proofing your IP. For example, any patents that you apply for should contain future developments as well as where the IP is today.

Thanks again to Jamie for his whistle-stop tour through the changing NHS landscape. If you’re interested in finding out more about the payer landscape of health care, then do sign up to our next Lunch&Learn on the 8th September.